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1 Page 1 MS Learn Online Feature Presentation Managing Symptoms: Vision Nancy Holland, Ed.D, RN, MSCN Tom>> Welcome to MS Learn Online, I m Tom Kimball Tracey>> And I m Tracey Kimball. People living with multiple sclerosis can experience a wide range of vision problems. One of the earliest symptoms that led to my diagnosis was optic neuritis. Tom>> Other vision problems include nystagmus and double vision. Dr. Nancy Holland, Vice President of Clinical Program with the National MS Society joins correspondent Rick Sommers and tells us that vision problems are a very common symptom of MS. >>Dr. Holland: First of all, about 80% of people with MS will have some kind of visual problem during the course of their illness, but you're exactly right about that leading them to the doctor. Because optic neuritis is the initial symptom for about half of people who have relapsingremitting MS, which is by far the most common disease course. So, yes, people -- often it's blurred vision or difficulty just seeing that starts out. But their optic neuritis actually has a lot of different components. >>Rick Sommers: Well, let's talk about those a little bit. >>Dr. Holland: Okay. Well, I mentioned the blurred vision. Decreased visual acuity. Now, what that means is, I don't know if you've heard the

2 Page 2 term Snellen chart. But that's when you go to see your doctor and there's the chart on the wall. The doctor says, "Cover your right eye and tell me how far down you can read." That is what gives you the visual acuity. And most people would love to have 20/20, but most of us don't. And, in fact, when you're experiencing optic neuritis, the visual acuity goes down a lot, which means you're just not seeing clearly, you don't have that distance vision. There are a number of other symptoms that occur, not all of them with everyone, like most things in MS. But the peripheral vision can be affected. Now, the peripheral vision is when you look up, down, to the right or left, it's kind of these fields, and the doctor tests it by usually wiggling -- the doctor or the nurse by wiggling fingers and saying, "Can you see my right hand?" So, the peripheral vision can be decreased as well, where people can see straight ahead but not off to the side or down very well. Then kind of the opposite of that is central vision. Sometimes people, there is like a hole in the middle of their vision. They look out and it's sort of like a black hole in the center, but they can see everything around it. I mentioned black hole, there is also a symptom called scotoma, which is when the person looks out and there are small black spots randomly in the visual field. >> Rick Sommers: And these are the kind of things that you could go to bed one night and wake up the next morning and be experiencing, or is it kind of a slow onset? >>Dr. Holland: No, actually, it's a very good question, because it tends to be a faster onset than that, usually over a course of several hours or several days the symptoms are experienced. Now, there are a lot of people who miss this, because it can be very minor. You talk to people and ask

3 Page 3 them if they've had visual problems and you'll hear, "Well, gee, when I was in college, for about a week I was having some blurred vision in one eye but I didn't pay attention to it and it just went away." So, it can be very, very mild. And fortunately no one is going to experience all of these symptoms. I'm just kind of outlining them so that people will have a sense of what's going on if they have these kinds of symptoms. >> Rick Sommers: I've heard about blindness, total loss of vision in an eye. How often do we see or hear that? >>Dr. Holland: Okay, that's very unusual, and the optic neuritis is one of those symptoms that tend to clear up almost entirely. Even total blindness, which can be very scary, it's hugely, almost always just in one eye, and will clear up. The treatment is generally intravenous steroids. >> Rick Sommers: Okay. >>Dr. Holland: In years past it was mostly oral steroids and then there was a large study done that suggested that the IV steroids worked better. But they really make the attack clear up faster and they relieve symptoms. Because one of the symptoms besides all of these things interfering with vision is sometimes people have pretty severe pain in that eye, and the steroids will clear that up very fast. So, that's the good news, that optic neuritis is common, but it tends to clear up almost all the time, faster with steroids, fewer symptoms with steroids. And half of the people start off with optic neuritis as the first symptom, which, if you can think of a good symptom, this optic neuritis is considered a sensory symptom. And if you look at long-term prognosis or long-term effect the disease is going to have, people who start off with a sensory symptom as their initial attack are, of course not always, but have a likelihood of having an easier disease course. So, even though it's a very, very scary symptom, the people can generally be reassured this is going to

4 Page 4 get better. And this is suggestive that you may not have a very serious course. >> Rick Sommers: As we started our discussion, you had mentioned seven categories or symptoms, I guess. >>Dr. Holland: Right, and we got through five of them, and the two actually -- and those are the five that tend to clear up just about entirely. There are two more symptoms that tend to persist if the person experiences them, and not everyone will. One is decreased color vision, and that is usually pretty subtle and only picked up on testing because it really is difficulty with subtle differences in color. It doesn't mean you're not going to see the bright colors or even the pale colors, but a person may have some difficulty distinguishing, like I say, subtler differences. >> Rick Sommers: But it's not as dramatic as driving not being able to tell if that's a green light or a red light. >>Dr. Holland: Oh, not at all. No, it's very, very subtle. But that tends to persist, unlike the other symptoms, which tend to clear up. >> Rick Sommers: Okay. >>Dr. Holland: And the other one that tends to persist, and this relates to driving, is decreased pupillary response. >> Rick Sommers: What does that mean? >>Dr. Holland: Okay, what that means is normally when bright light hits the eye, the pupil, which is the black part in the center of the eye, closes up to minimize the impact of the bright light on the eye. After a person's optic neuritis, that response can be slowed down, so that bright lights are more problematic. And the most common complaint that reflects this symptom is night driving, okay?

5 Page 5 >> Rick Sommers: Right. >>Dr. Holland: People will say, "I can't stand driving at night, the headlights feel like they're blinding me." And the thing that usually is very, very helpful for this is the Polaroid lenses in the sunglasses, like -- >> Rick Sommers: Tinted lenses? >>Dr. Holland: Yes, specifically the Polaroid ones will adapt to the light coming in and will really minimize that effect, so it's certainly a very manageable kind of -- >> Rick Sommers: But in all fairness, I mean, this is also just a symptom of getting older as well, it's not just an MS-related thing. I mean, I've heard parents say, yeah, I can't drive at night anymore because the headlights coming at me are just too tough to take. >>Dr. Holland: You're absolutely right. Things do slow down as we get older, and that can certainly be one of them. >> Rick Sommers: Dr. Holland, we talked about optic neuritis. What are some of the other symptoms that will impact people? >>Dr. Holland: Okay, there are a few other symptoms that are certainly much less common than optic neuritis, but it's good for people to have a sense of what they are in case they're experiencing some of the symptoms. One is nystagmus. Now, that's a rapid eye movement, where the eye is moving to the right and the left in kind of a rapid fashion, and that's where we were talking about the neurologic exam. That's when the doctor goes like that and it may be very subtle. A person may not even be having much of a symptom from that, but the doctor will pick up that the eye is going back and forth a little bit.

6 Page 6 And there is one more, and that's double vision. One form if visual disturbance that people can experience is seeing two images simultaneously, which is pretty disconcerting. Sometimes that can be helped, until the episode clears up, just by covering one eye and rotating which eye is covered. But that will go away. >> Rick Sommers: I wanted to ask, these symptoms, do they generally impact both eyes at the same time, or is it one eye remains pretty normal, the other eye is the one that's affected? >>Dr. Holland: Well, these eye movement problems tend to be both eyes. >> Rick Sommers: Okay. >>Dr. Holland: As opposed to the optic neuritis, which is really just the one eye. Tracey>> Despite the fact that vision problems can be quite frightening, it s good to know that these symptoms are generally temporary. Tom>> If you want more information on vision symptoms contact the National MS Society or of course talk to your doctor. Tracey>> Thank you for joining us for MS Learn Online.

Optic Neuritis Your doctor thinks that you have had an episode of optic neuritis. This is the most common cause of sudden visual loss in a young patient. It is often associated with discomfort in or around

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